The Unfinished Edifice: A Narrative Timeline of the Affordable Care Act

For years, as a health policy expert, I struggled to explain the Affordable Care Act (ACA). My attempts to present it as a linear sequence of events—a bill passed, a court case decided, a provision implemented—invariably failed. The approach created a confusing tangle of dates, acronyms, and political jargon that left audiences more bewildered than enlightened.¹ It captured the

what but consistently missed the why. The story felt disjointed, like a pile of bricks and lumber with no blueprint.

The breakthrough came when I abandoned the simple timeline and began to see the ACA not as a single event, but as a massive, multi-generational construction project. This “Unfinished Edifice” is a structure built upon the foundations of a century of abandoned designs, erected during a political hurricane, immediately besieged by legal earthquakes and a relentless demolition crew, and is still undergoing renovations today. This paradigm transforms the timeline from a confusing list into a coherent, dynamic story of creation, conflict, and evolution. To truly understand the ACA, one must view it through this architectural lens, examining the historical blueprints, the pouring of the foundation, the framing of the structure, the seismic legal challenges that reshaped it, the ongoing political battles over its existence, and finally, a post-occupancy evaluation of its impact.

Part I: The Historical Blueprints: A Century of Abandoned Designs (Pre-2009)

To understand the architecture of the Affordable Care Act, one must first walk through the graveyard of abandoned blueprints that preceded it. For nearly a century, the United States stood as a notable exception among industrialized nations for its lack of a national health insurance system.³ This was not for lack of trying. The history of American healthcare is littered with failed reform efforts, each leaving behind lessons and unresolved problems that would directly shape the ACA’s design.

A Legacy of Failed Reforms

The push for national health reform began as early as 1912, when Theodore Roosevelt’s Progressive Party platform called for a national health service.⁵ In the 1930s, President Franklin D. Roosevelt considered including a publicly funded healthcare program in his Social Security Act but ultimately removed it amid fierce opposition from groups like the American Medical Association (AMA), which successfully branded the idea as “compulsory health insurance”.⁵ This pattern repeated itself when President Harry S. Truman proposed a universal health plan in the late 1940s; the AMA ramped up its campaign, equating the proposal with “socialized medicine” and effectively killing it in a climate of rising anti-communist sentiment.⁴

A pivotal, and largely accidental, turn occurred during World War II. The Stabilization Act of 1942, which imposed wage and price controls, led employers to offer health insurance as a fringe benefit to attract workers.³ A 1951 IRS ruling that made these employer contributions a tax-deductible business expense cemented this employer-sponsored system as the bedrock of American health coverage.⁴ This historical accident, not a deliberate design, created a patchwork system that was inherently fragile.

The most significant pre-ACA reform was the creation of Medicare and Medicaid in 1965 under President Lyndon B. Johnson.³ While a monumental achievement, it reinforced the fragmented nature of the system by carving out programs for the elderly and the very poor, leaving a vast and growing coverage gap for working-age adults and their families. Subsequent decades saw a series of high-profile failures, including proposals from Presidents Nixon and Clinton, that further underscored the political difficulty of comprehensive reform.⁴ The collapse of the Clinton plan in 1994, in particular, offered a crucial lesson for future reformers about the dangers of crafting policy in secret and underestimating the power of industry opposition and public anxiety.⁷

The System at its Breaking Point

By the late 2000s, this patchwork system was collapsing under its own weight, creating a multi-faceted crisis that made reform a political and economic imperative. Public dissatisfaction was rampant, with one 2008 poll finding that 82% of Americans wanted the healthcare system overhauled.⁹ The system was failing on three critical fronts: access, security, and cost.

The Uninsured Crisis: The number of uninsured Americans had swelled to nearly 50 million by 2010, representing about one in six people.⁹ The uninsured rate for the entire population stood at 16%, but for working-age adults (18-64), it was a staggering 22.3%.¹⁰ This crisis was fueled by the steady erosion of employer-sponsored insurance, which had declined significantly over the preceding decade as costs spiraled.¹¹

The Tyranny of Pre-Existing Conditions: For those without employer coverage who sought insurance on the individual market, the system was often cruel and dysfunctional. In most states, insurers could practice “medical underwriting,” meaning they could deny coverage outright, charge dramatically higher premiums, or refuse to cover services related to a pre-existing condition.¹² These conditions could be as serious as cancer or diabetes, or as common as asthma, acne, or pregnancy.¹³ This practice created the phenomenon of “job lock,” where people felt trapped in their jobs, afraid to become entrepreneurs or change careers for fear of losing their health insurance.⁹

The Affordability Crisis: Healthcare costs were not just a problem for individuals; they were a drag on the entire U.S. economy. In 2009, U.S. health spending consumed nearly 18% of the nation’s Gross Domestic Product (GDP)—far more than any other developed country, yet with worse health outcomes on measures like life expectancy and infant mortality.⁹ Between 2000 and 2009, the cost of an average employer-sponsored family plan had soared by 131%.⁹ Even for those with insurance, lifetime limits on coverage meant that a serious illness could lead to financial ruin.¹⁶

The foundation of the ACA was thus a direct response to the systemic failures of this fragmented, employment-based system. Its core components—the marketplaces, subsidies, and insurance regulations—were specifically engineered to create a viable alternative for the millions of people left behind. However, the political landscape was treacherous. While polls showed broad support for reform in the abstract, that support tended to fracture when specific trade-offs, like new taxes or government mandates, were introduced.⁸ This dynamic, where the public supported the goal but opposed the necessary mechanisms, meant that any legislative proposal would be intensely vulnerable to political attack.

Metric	Status Circa 2009-2010	Source(s)
Total Uninsured Americans	Approx. 48-50 million	9
Uninsured Rate (All Ages)	Approx. 16.0%	10
Uninsured Rate (Working-Age Adults 18-64)	Approx. 22.3%	10
Increase in Family Premiums (2000-2009)	131%	9
U.S. Health Spending as % of GDP	Approx. 17.9%	9
Pre-Existing Condition Denials	Permitted in most states’ individual markets	12
Public Dissatisfaction with Healthcare System	82% wanted system overhauled	9

Part II: Pouring the Foundation: The Tumultuous Passage of the ACA (2009–2010)

The construction of the ACA was a year-long legislative marathon, marked by strategic compromises, intense partisan warfare, and dramatic political maneuvers. Learning from the Clinton administration’s failed top-down approach, President Obama’s team opted to let Congress take the lead in drafting the bill, hoping a more open process would build consensus.⁷ Key political architects included President Obama, who framed the effort as both a moral and economic imperative, alongside House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid, who steered the complex legislation through their respective chambers.¹⁸

The legislative journey began in July 2009 with the introduction of the “Affordable Health Care for America Act”.²⁰ The process was immediately fraught with challenges. The death of Senator Ted Kennedy in August 2009, a lifelong champion of health reform, complicated the delicate vote-counting in the Senate.²⁰ After months of debate, the House of Representatives passed its version of the bill on November 7, 2009, by a narrow margin of 220-215.¹⁸ In a dramatic Christmas Eve session, the Senate passed its version, 60-39, with no Republican support.¹⁸

The victory was short-lived. In January 2010, a special election in Massachusetts cost the Democrats their 60-vote, filibuster-proof supermajority, forcing a major change in strategy.²⁰ To get the bill over the finish line, Democratic leaders employed a complex legislative maneuver known as budget reconciliation, which allows certain budget-related bills to pass the Senate with a simple majority. On March 21, 2010, the House passed the Senate’s bill, 219-212.¹⁸ President Barack Obama signed the Patient Protection and Affordable Care Act into law on March 23, 2010.²⁰

The lack of any bipartisan support for the final legislation was a critical development. Unlike Medicare, which passed with votes from both parties, the ACA was enacted on a strictly party-line basis.¹⁸ This decision, born of political necessity in a hyper-partisan environment, baked political polarization into the law’s DNA. From the moment of its passage, the ACA was not seen as a settled national policy but as a partisan victory to be overturned, setting the stage for a decade of relentless political warfare.²³

The Architectural Core: The Three-Legged Stool

At the heart of the ACA’s design to fix the broken individual insurance market is a concept known as the “three-legged stool,” an interlocking set of policies where each component is essential for the structure’s stability.²⁵

1. Leg 1: Insurance Market Reforms. This leg includes the law’s most popular provisions: “guaranteed issue,” which prevents insurers from denying coverage to people with pre-existing conditions, and “community rating,” which limits the ability of insurers to charge sick people higher premiums.²⁵ On its own, this leg is unstable. If insurers must cover everyone at similar rates, healthy people might wait until they get sick to buy insurance. This leads to a sicker, more expensive insurance pool, causing premiums to skyrocket in a “death spiral”.²⁷
2. Leg 2: The Individual Mandate. To counteract the death spiral, the second leg required most Americans to maintain health insurance or pay a penalty. This was designed to ensure that both healthy and sick people were in the insurance pool, spreading the risk and keeping premiums affordable for everyone.²⁷
3. Leg 3: Subsidies. The mandate would be unfair if people could not afford the insurance they were required to buy. The third leg addresses this with federal financial assistance. Premium tax credits lower the monthly cost of coverage, and cost-sharing reductions lower out-of-pocket expenses like deductibles and copayments for low- and middle-income families.²⁶

This three-legged design, modeled on the successful 2006 Massachusetts health reform, was the ACA’s core architectural solution to the individual market crisis.²⁶ The subsequent history of the law is largely a story of political and legal attacks on one or more of these essential legs.

Part III: Framing the Structure: The Phased Implementation of a New System (2010–2018)

The ACA was not built overnight. Its implementation was a deliberately phased construction project, designed to roll out popular, easy-to-implement provisions first to build public support before the more complex and controversial elements went live. This strategic calculation created both early momentum and long-term vulnerabilities, as it gave opponents years to attack the law before its main benefits were fully realized by millions of Americans.

Phase 1 (2010–2011): Early Wins and Popular Provisions

The initial phase focused on immediate, tangible benefits that served as “ribbon-cutting” moments for the new law. Within the first year, several key provisions took effect:

• Young adults could remain on their parents’ health insurance plans until age 26.²⁰
• Insurance companies were prohibited from denying coverage to children with pre-existing conditions.³¹
• Lifetime dollar limits on essential health benefits were banned, and annual limits were restricted.¹⁶
• Many preventive services, such as cancer screenings and immunizations, became available with no out-of-pocket costs for patients.²⁰
• A program began to close the Medicare Part D prescription drug coverage gap, known as the “donut hole,” providing relief for seniors.³¹

Phase 2 (2012–2013): Building the Infrastructure

This period involved the complex back-end work required for the law’s main launch. The Center for Medicare and Medicaid Innovation (CMMI) was established to begin testing new payment and delivery models aimed at lowering costs and improving quality.³⁰ The most visible event of this phase was the launch of the federal Health Insurance Marketplace, HealthCare.gov, on October 1, 2013. The launch was plagued by widespread technical failures, creating a major political and public relations disaster for the administration and providing a powerful negative narrative for opponents just as the law’s core functions were supposed to be coming online.³⁰

Phase 3 (2014): The “Go-Live” Year

January 1, 2014, marked the moment the full ACA edifice became operational. This was the most significant year of the implementation timeline:

• Health Insurance Marketplaces, both state-run and federal, officially opened for business, allowing individuals and small businesses to shop for standardized health plans categorized as Bronze, Silver, Gold, and Platinum.³³
• Federal subsidies, including premium tax credits and cost-sharing reductions, began to flow to eligible enrollees, making coverage affordable for millions.²
• The ban on denying coverage or charging more for pre-existing conditions was extended to all adults.¹⁴
• The individual mandate took full effect, with most people required to have coverage or face a penalty on their tax returns.²⁰
• Medicaid eligibility was expanded to adults with incomes up to 138% of the federal poverty level in states that chose to participate.³⁰

Phase 4 (2015–2018): Refinements and Political Headwinds

In the following years, the final major provisions were rolled out and the political attacks intensified. The employer mandate, requiring businesses with 50 or more full-time employees to offer affordable coverage, was fully phased in.³⁰ The most significant change during this period came in December 2017, when the Tax Cuts and Jobs Act effectively repealed the individual mandate by reducing the penalty to $0, starting in 2019.³⁰ This action removed one of the three legs of the stool, raising concerns about the long-term stability of the marketplaces.

Year	Key Provision Implemented	Purpose/Significance	Source(s)
2010	Coverage for young adults up to age 26; Ban on lifetime limits; Pre-Existing Condition Insurance Plan (PCIP) created.	Provided immediate, popular benefits and a safety net for the uninsurable.	30
2011	Free preventive care for many plans; Medicare “donut hole” rebates.	Reduced out-of-pocket costs for high-value care and for seniors on Medicare.	20
2012	Hospital Value-Based Purchasing program begins.	Began shifting Medicare payments from volume to value and quality.	30
2013	HealthCare.gov and state marketplaces launch.	Created the new infrastructure for purchasing individual market insurance.	30
2014	Marketplaces open with subsidies; Medicaid expansion begins; Individual mandate enforced; Guaranteed issue for all.	The ACA’s core coverage expansion architecture becomes fully operational.	30
2016	Employer mandate fully phased in for large employers.	Expanded the requirement for employers to offer affordable coverage.	30
2017	Individual mandate penalty repealed (effective in 2019).	Removed a key leg of the “three-legged stool,” a major political blow to the law.	30

Part IV: The Legal Earthquakes: How the Supreme Court Reshaped the Building

No sooner was the ACA’s foundation poured than a series of legal earthquakes threatened to bring the entire edifice down. The law faced three existential challenges at the U.S. Supreme Court, and the Court’s decisions did more than just uphold or strike down the law—they fundamentally altered its design. In this sense, the Supreme Court acted not just as an arbiter but as a co-architect of the ACA, reshaping its structure in ways that continue to define its impact today.

National Federation of Independent Business v. Sebelius (2012): The Foundation is Shaken but Holds

The first and most significant legal challenge took aim at two of the law’s central pillars: the individual mandate and the mandatory expansion of Medicaid.³⁵ In a landmark 5-4 decision, the Court delivered a split verdict that saved the law while profoundly changing it.

• The Ruling: Chief Justice John Roberts, writing for the majority, concluded that the individual mandate was not a constitutional use of Congress’s power to regulate interstate commerce, as the government cannot compel individuals to engage in commerce.³⁶ However, he found that the penalty for not having insurance could be reasonably interpreted as a tax, which is within Congress’s constitutional authority.³⁸ In a separate part of the ruling, the Court found that the law’s requirement for states to expand their Medicaid programs or risk losing all existing federal Medicaid funding was unconstitutionally coercive.³⁸
• The Impact: By upholding the mandate as a tax, the Court allowed the “three-legged stool” to stand. But by making the Medicaid expansion optional for states, the decision created the “Medicaid gap”—a situation in non-expansion states where millions of low-income adults earn too much to qualify for traditional Medicaid but too little to receive subsidies in the marketplace. This single judicial alteration is the direct cause of the deep coverage disparities that exist today between expansion and non-expansion states.⁴¹

King v. Burwell (2015): Reinforcing a Critical Support Beam

The second major challenge focused on just four words in the massive law: “an Exchange established by the State”.⁴³ Opponents argued this phrase meant that federal subsidies were illegal in the dozens of states that had not created their own marketplaces and were instead relying on the federal HealthCare.gov platform.

• The Ruling: In a 6-3 decision, the Court rejected this argument. Looking at the broader context and purpose of the law, the majority concluded that Congress clearly intended for subsidies to be available to all eligible Americans, regardless of whether their state ran its own exchange or used the federal one.⁴³
• The Impact: A ruling for the plaintiffs would have been catastrophic for the ACA, immediately making insurance unaffordable for millions of people and triggering a death spiral in the majority of states. The King v. Burwell decision stabilized the marketplaces and preserved the law’s core function.

California v. Texas (2021): Fending Off a Final Demolition Attempt

The final existential threat came after the 2017 tax law zeroed out the financial penalty for the individual mandate. Opponents crafted a new legal theory: since the mandate no longer raised revenue, it could no longer be considered a tax and was therefore unconstitutional. They further argued that the mandate was so central to the law that the entire ACA must fall with it.⁴⁴

• The Ruling: The Court dismissed the case in a 7-2 decision on procedural grounds. It held that the plaintiffs lacked the legal right, or “standing,” to bring the lawsuit because a mandate with a $0 penalty caused them no financial harm.⁴⁴
• The Impact: By dismissing the case on standing, the Court avoided ruling on the merits of the constitutional argument. However, the decision effectively ended the last major legal threat to the ACA’s existence, allowing the now-decade-old law to stand.

Case	Year	Core Legal Question	Court’s Decision	Impact on the ACA
NFIB v. Sebelius	2012	Is the individual mandate constitutional? Is mandatory Medicaid expansion coercive?	Mandate upheld as a tax. Medicaid expansion made optional for states.	Preserved the “three-legged stool” but created the “Medicaid gap” and state-by-state disparities.
King v. Burwell	2015	Are subsidies legal in states using the federal marketplace?	Yes, subsidies are available nationwide.	Stabilized the health insurance marketplaces in over 30 states, preventing their collapse.
California v. Texas	2021	Is the entire ACA unconstitutional now that the mandate penalty is $0?	Case dismissed on procedural grounds (lack of standing).	Ended the last major existential legal threat, preserving the law.

Part V: The Wrecking Crew vs. The Renovation Team: A Decade of Political Warfare

From the moment it was signed, the ACA became the central battleground in American politics. The ensuing decade can be understood as a relentless struggle between a “wrecking crew” seeking to demolish the edifice and a “renovation team” seeking to repair and strengthen it. This conflict played out in Congress, in the executive branch, and in the court of public opinion.

The Repeal-and-Replace Campaign (2011–2017)

For seven years, “repeal and replace” was the unifying rallying cry of the Republican party.²² Between 2011 and 2017, the House of Representatives voted more than 70 times to repeal, defund, or alter the law.²³ These efforts culminated in 2017, when Republicans controlled the Presidency and both houses of Congress. However, when they finally had the power to act, they discovered deep internal divisions over what a “replacement” should actually look like.⁴⁶

The main legislative vehicles, the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA), faced intense public backlash as analysis showed they would lead to millions losing coverage and weakened protections for people with pre-existing conditions.²⁴ The dramatic legislative battle ended in the early morning hours of July 28, 2017, when Senator John McCain joined two other Republican colleagues and all Democrats in voting against a “skinny repeal” bill, causing it to fail by a single vote.³⁴ The failure of the 2017 repeal effort was a pivotal turning point. It exposed the political difficulty of taking away established benefits and effectively shifted the national debate from “repeal and replace” to “repair and improve.”

The War by a Thousand Cuts and the Renovation Response

After the legislative failure, the Trump administration shifted to undermining the law through executive action. These actions included ending direct payments to insurers for cost-sharing reductions, which destabilized premiums; slashing funding for outreach and enrollment assistance (navigators) by over 80%; and promoting the sale of short-term, “junk” insurance plans that were not required to meet ACA standards.⁷

Conversely, the Biden administration has focused on strengthening the ACA. The 2021 American Rescue Plan and the 2022 Inflation Reduction Act dramatically enhanced and expanded the law’s premium subsidies, making coverage significantly more affordable for millions and leading to record-breaking enrollment in the marketplaces.⁷ Funding for navigators and outreach was also restored.⁷

The Surprising Shift in Public Opinion

Perhaps the most unexpected outcome of this political war was its effect on public opinion. For most of its early life, the ACA was unpopular, with polls consistently showing more Americans opposing the law than supporting it.⁸ This began to change dramatically during the 2017 repeal debate. As the threat of losing the law’s protections became real, public support surged. For the first time, a majority of Americans held a favorable view of the ACA, a trend that has largely continued since.⁴⁵ The relentless attacks, paradoxically, solidified the law’s place in the American social fabric.

Figure 1: Public Opinion on the Affordable Care Act (2010-2023)

(A line graph would be displayed here, plotting the percentage of the public with “Favorable” vs. “Unfavorable” views over time, based on Kaiser Family Foundation polling data.50 The graph would be annotated with key events: “ACA Signed (Mar 2010),” “NFIB v. Sebelius (Jun 2012),” “GOP Repeal Attempt (Jul 2017),” and “American Rescue Plan (Mar 2021)” to illustrate how political events correlated with shifts in public sentiment.)

Part VI: A Post-Occupancy Evaluation: The ACA’s Measured Impact on American Health

More than a decade after its passage, it is now possible to conduct a “post-occupancy evaluation” of the ACA edifice. A review of extensive data reveals a clear record of success in its primary goal of expanding coverage, with more mixed but still positive results for affordability and emerging evidence of improved health outcomes. However, the law’s impact is not monolithic; it is a tale of two Americas, largely defined by the state-by-state decision on Medicaid expansion that resulted from the Sebelius ruling.

Coverage Expansion: An Undeniable Success

The ACA’s greatest achievement has been the dramatic reduction in the number of uninsured Americans. The national uninsured rate fell from a high of over 45 million people in 2013 to a historic low of around 26 million in 2022.⁴²

• Closing Gaps: Coverage gains have been particularly large for people of color, significantly narrowing long-standing racial and ethnic disparities in health coverage.⁴²
• Medicaid’s Role: The majority of these gains occurred in the 40 states (plus D.C.) that chose to expand their Medicaid programs. In these states, the uninsured rate plummeted as millions of low-income adults gained coverage.⁴¹
• Marketplace Growth: Bolstered by enhanced subsidies, enrollment in the ACA marketplaces has reached record highs, with roughly 40 million people covered between the marketplaces and Medicaid expansion today.⁷

Affordability and Financial Security

For those receiving assistance, the ACA has made coverage significantly more affordable.

• Lower Premiums: In 2019, before the most recent subsidy enhancements, the average marketplace enrollee paid just $87 per month for their premium after financial aid was applied.⁵³ With the enhanced subsidies from the American Rescue Plan, many enrollees can find plans for $10 or less per month.
• Reduced Medical Debt: Medicaid expansion has been linked to significant improvements in financial security for low-income families, including fewer struggles with medical bills and reductions in medical debt sent to collection.⁵²
• Access to Care: The law has had a tangible impact on whether people can afford to use their coverage. Between 2010 and 2018, the share of non-elderly adults who skipped needed medical care due to cost fell by 24%.⁵³ Studies on cancer patients found that the ACA led to significant reductions in out-of-pocket spending for the lowest-income groups.⁵⁴

Health Outcomes: Emerging Positive Evidence

While it can take many years for the health effects of coverage to become clear, a growing body of research points to positive trends.

• Improved Health and Early Detection: Multiple reviews of dozens of studies have found encouraging evidence that the ACA’s coverage expansions are associated with improvements in self-reported health, better management of chronic conditions like diabetes, and increased early detection of cancer.⁵⁵
• Lives Saved: The impact on mortality is significant. One major 2019 study estimated that Medicaid expansion was associated with 19,200 fewer deaths among low-income older adults between 2014 and 2017. The study also calculated that an additional 15,600 deaths could have been prevented during that period if the remaining non-expansion states had expanded their programs.⁵³

The data clearly shows that the full potential of the ACA has been blunted by the optional nature of Medicaid expansion. Coverage gains, affordability improvements, and positive health outcomes are all significantly greater in states that adopted the expansion compared to those that did not.⁴¹ A person’s access to the full benefits of this national law remains heavily dependent on their zip code—a direct and lasting consequence of the interplay between the original legislative text and its subsequent judicial reshaping.

Demographic Group	Uninsured Rate (2013)	Uninsured Rate (2022)	Source(s)
All Non-Elderly Americans	16.6%	9.6%	47
Black Americans (Non-Elderly)	18.7%	9.9%	42
Latino Americans (Non-Elderly)	29.7%	17.8%	42
Residents in Medicaid Expansion States	N/A (Gap shrank by 51% for Black adults and 45% for Hispanic adults)	N/A	52
Residents in Non-Expansion States	N/A (Gap shrank by 33% for Black adults and 27% for Hispanic adults)	N/A	52

Conclusion: The Unfinished Edifice

The timeline of the Affordable Care Act is not a simple chronology of dates and events. It is the complex, ongoing story of an Unfinished Edifice. It is a structure built on the contested ground of a century of failed reforms, with a foundation poured in the midst of a political tempest. Its design was fundamentally altered mid-construction by judicial earthquakes, and it remains under constant threat from demolition crews even as renovation teams work to shore up its walls and expand its reach.

Its legacy, thus far, is one of resilience. The ACA’s survival through relentless legislative, judicial, and political assaults has transformed it from a partisan lightning rod into a permanent, if still debated, feature of the American social contract. It has provided coverage to tens of millions, protected countless families from financial ruin, and begun to bend the curve toward better health outcomes.

Returning to the architect’s dilemma, it is clear that understanding the ACA requires moving beyond a list of provisions. One must see it as this living, evolving structure—a testament to the immense difficulty of enacting major social policy in a deeply polarized nation. Its timeline is not a static record of what was built, but the living biography of an edifice that is, and will likely always be, under construction.

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